Located in:

Duties and Responsibilities

The duties include, but are not limited to:

• Develop constructive relationships with local hospitals admission offices, case managers and discharge planners.
• Work to develop systems, processes, and initiatives to engage these entities in relevant case management activities with high-risk members of the practice ensuring necessary post discharge needs are met.
• Monitor to ensure care is coordinated with home care agencies, specialists, or other resources needed.
• Monitor to make sure follow-up primary care visits are obtained within 24 hours of hospital discharge.
• Conduct follow-up to ensure that initial patient assessment and post-visit consultation includes a comprehensive medical, psychosocial, and that functional assessment of the patient are all completed and in order as identified by the patient centered medical home.
• Communicate with and coach patients to ensure they are aware of discharge instructions, have necessary prescriptions, access to medications, and understand how to take the necessary medications, including what to look for regarding adverse events as per their care givers instructions.
• Monitor that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team.
• Coordinate necessary referrals and authorizations within care management areas.
• Facilitate the information flow between hospital, long-term care, specialists and home health representatives and the care team.
• Work with physician and office staff to help identify high risk, high need, and potentially high-cost patients.
• Assist physicians and care team in implementing processes for best practices for preventive services, chronic care, and disease management.
• Work collaboratively with physicians and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease-specific screenings, interventions, treatment goals – including self-management goals, and contract schedules.
• Coordinate care and communicate with multiple providers, both within and external to the practice.
• Identify and utilize cultural and community resources.
• Verify that practice has necessary behavioral health screening tools (depression / substance abuse), and all members are receiving appropriate screening and behavioral health interventions.
• Facilitate any necessary follow-up behavioral health needs with local behavioral health providers.
• Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled.
• Assess patient needs and develop a plan of action to address needs in collaboration with the primary care physician.
• Provide and facilitate open communication, regarding patient status, with physicians and office staff.
• Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts.
• Performs miscellaneous job-related duties as assigned

Qualifications or Education, Training and Experience

• Graduation from an accredited and approved nursing program
• Active RN license in good standing required.
• Certified Case Management (CCM) certification preferred
• APM (CPC+, BPCI, MSSP) and MA experience preferred
• Experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan
• 5 to 8 years of direct patient care experience required

Knowledge and Skills/Expected Competencies

Working knowledge of the following required:

• Principles of utilization management; Case/care management principles; Health care contracts and benefit eligibility requirements; Hospital structures and payment systems; Basic PC skills (MS Word/Outlook/PPT/Excel)

Competencies:

• Ability to use independent judgment and to manage and impart confidential information.
• Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.
• Strong communication and interpersonal skills.
• Ability to clearly communicate medical information to professional practitioners and/or the public.
• Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.
• Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.
• Dependable, with strong work ethic and extremely high degree personal integrity.
• Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.
• Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
• Ability to review critical issues, effectively solve problems and create action plans.